CHF EVIDENCED BASED PROTOCOL AND REFERENCES

Draft Version 1.0

January 28, 2018

Framingham criteria for congestive heart failure (CHF) [45] For establishing a definite diagnosis of CHF, 2 major criteria or 1 major and 2 minor criteria must be present. Major criteria are:

• Paroxysmal nocturnal dyspnea or orthopnea • Neck-vein distention • Rales • Cardiomegaly • Acute pulmonary edema • S3 gallop • Increased venous pressure >16 cm of water • Circulation time 25 seconds or longer (no longer used clinically

for the diagnosis of CHF, although in the criteria) • Hepatojugular reflux.

Minor criteria are: • Ankle edema • Night cough • Dyspnea on exertion • Hepatomegaly • Pleural effusion • Vital capacity reduced one third from maximum • Tachycardia (≥120 bpm).

Major or minor criteria are: • Weight loss of 4.5 kg or more in 5 days in response to treatment.

Diagnose Heart Failure (Stage C) or Patient at Risk for Heart Failure (Stage A and B)

Possible total of 14: [25] • Age >75 years - score 1 • Orthopnea present -

score 2 • Lack of cough - score 1 • Current use of a loop

diuretic (before presentation) - score 1

• Rales - score 1 • Lack of fever - score 2 • Elevated N-terminal pro-

brain natriuretic peptide (NT-proBNP)* - score 4

• Interstitial edema on CXR - score 2.

Likelihood of heart failure: • Low: 0 to 5 • Intermediate: 6 to 8 • High: 9 to 14

. * Elevated NT-proBNP defined as >450 pg/mL if age <50 years and >900 pg/mL if age >50 years

New York Heart Association (NYHA) clinical classification of heart failure [3]

Class I: asymptomatic

Class II: mild symptoms with moderate exertion

Class III: symptoms with minimal activity

Class IV: symptoms at rest.

Heart Failure Preserved EF

Exercise Induced Diastolic Dysfunction

Typical Patient

Long standing HTN NYHAII Exercise Intolerance Minimal Fluid Retention NO HF Hospitalizations LVEF 70% 2+ Left Atrial Enlarge Grade 1-2 DD Pulm Art Press 10-25

Volume Overload

Typical Patient

HTN CAD S/P CABG NYHA III Severe DOE 2+ Edema Recent HF Hospitalization LVEF 50% 3+ Left Atrial Enlarge Grade III DD Pulm Art Press 45 at rest

Pulmonary HTN RV Failure

Typical Patient

HTN DM CKD Obese NYHA III Severe DOE, SOB 3+ Edema , ascites Frequent HF Hospitalization LVEF 65% 4+ Left Atrial Enlarge Grade IV DD Pulm Art Press 60 at rest RVH + RV dysfunction

• CHF annual incidence approaches 10 per 1,000 population after 65 years of age.

• The incidence of CHF is equally frequent in men and women, and African-Americans are 1.5 times more likely to develop heart failure than Caucasians.

• Heart failure is responsible for 11 million physician visits each year, and more hospitalizations than all forms of cancer combined.

• CHF is the first-listed diagnosis in 875,000 hospitalizations, and the most common diagnosis in hospital patients age 65 years and older.

• In that age group, one-fifth of all hospitalizations have a primary or secondary diagnosis of heart failure.

• More than half of those who develop CHF die within 5 years of diagnosis.

• Heart failure contributes to approximately 287,000 deaths a year. • Sudden death is common in patients with CHF, occurring at a

rate of six to nine times that of the general population. • Deaths from heart failure have decreased on average by 12

percent per decade for women and men over the past fifty years • Cost to treat heart failure is about $35 billion and will approach

$45 billion by 2020 and $70 billion by 2030

ALIGNMENT CHF PROGRAM designed to work with you to co-manage your more difficult patients as well as avoid unnecessary referrals or testing Enrollment Criteria: • CHF with NYHA Class III or IV symptoms • EF <50% • Hospitalization for CHF within the past 12 months

Services available: • Phone and Care Center based cardiology consultation and management with Dr. Kolappa (Cardiologist) • Video enabled home monitoring • Home visits for acute/chronic care • IV Lasix in Care Center (coming soon) • Social worker/behavioral health • Nutritionist

Program Referral: • Call Raleigh Main Line (919)-803-4820 or send in Care Center Referral form • For immediate attention Call Dr. Kamal Kolappa (919)-897-3382

Alignment Patient with Congestive Heart Failure

Maximize GDMT (Guideline Directed Medical Therapy)

(see attached tables and diagrams)

Stable continue current RX and follow-up Review any current specialty referrals or

testing for medical necessity

If patient meets criteria get them set up with Alignment for Chronic Disease

Management No Cost to Patient. Access to Care Coordinators, Dietician, Medication

Assistance and other services

Patient Not Responding to Maximum treatment but not meeting criteria for

acute admission

Before sending to ER or Specialist Call Kolappa or Extensvist on-call through

Alignment’s main number. They may be able to see patient promptly

or approve immediate referral No patient copay to use care center

Patient in your office or calls and not responding to diuretics for volume overload but medically

stable to be treated as out patient

Give Patient CHF ZONE Handout to monitor progress (attached to this document)

Before sending to ER or Specialist Call Kolappa or Extensvist on-call through

Alignment’s main number. Care Centers will be able to give IV

diuretics to avoid ER and patient copay

Based on your comfort level in treating CHF Criteria to Consider Referral to Care Center or Dr. Kolappa

(No cost to patient. Not a replacement for their Cardiologist. Help in Co-manage medical condition more cost-effectively

- Repeated >=2 hospitalizations or EF for HF in past year - Progressive Deterioration in renal function - Weight loss without other cause (cardiac cachexia) - Intolerance to ACE due to hypotension and or worse renal function - Intolerance to beta blockers due to worsening HF or hypotension - Frequent systolic blood pressure < 90 mm Hg - Persistent dyspnea with dressing and bathing requiring rest - Inability to walk 1 block on level ground due to dyspnea or fatigue - Recent need to escalate diuretics to maintain volume status can reach

daily Lasix dose of > 160 and using supplemental metolazone therapy - Progressive decline in serum sodium usually < 133 - Frequent ICD shocks

(Adapted from Russell et al Congestive Heart Fail 2008;4:316-21

If after-hours can call the on-call provider for Alignment to arrange immediate care center follow-up or have patient contact on-call Alignment provider for instructions prior to sending to ER

Other Triggers to consider referral to Alignment Care Center as well as Alignment Chronic Disease Management and case managers 1. New onset HF (regardless of EF) for evaluation of etiology, guideline-directed evaluation and management of recommended therapies, and assistance in disease management.

2. Chronic HF with high-risk features, such as development of 1 or more of the following risk factors: • ▪ Persistent NYHA functional class III–IV symptoms of congestion or profound fatigue • ▪ Systolic blood pressure ≤90 mm Hg or symptomatic hypotension • ▪ Creatinine ≥1.8 mg/dL or BUN ≥43 mg/dL • ▪ Onset of atrial fibrillation or ventricular arrhythmias or repetitive ICD shocks • ▪ Two or more emergency department visits or hospitalizations for worsening HF in prior 12

months • ▪ Inability to tolerate optimally-dosed beta blockers and/or ACEI/ARB/ARNI and/or aldosterone

antagonists • ▪ Clinical deterioration as indicated by worsening edema, rising biomarkers (BNP, NT-proBNP,

others), worsened exercise testing, decompensated hemodynamics, or evidence of progressive remodeling on imaging

• ▪ High mortality risk using validated risk model for further assessment and consideration of advanced therapies

• (http://www.onlinejacc.org/content/62/16/e147/T10)

Consider other factors for treatment failures . Alignment’s Care Managers and Social Workers can help mitigate these issues. Just complete Care Center referral form Patient

• Perceived lack of effect • Poor health literacy • Physical impairment (vision, cognition) • Depression and social isolation • Cognitive impairment • High HF regimen complexity • Polypharmacy due to multiple comorbidities • Frequency of dosing • Polypharmacy • Side effects • Socioeconomic • Out-of-pocket cost • Difficult access to pharmacy • Lack of support • Poor communication • No automatic refills

HEART FAILURE AT RISK FOR HEART FAILURE

Stage A At risk for HF but

without structural heart disease or symptoms of HF

Stage B Structural heart disease without

signs or symptoms of HF

Patients with -Hypertension -Atherosclerotic Disease -Diabetes -Obesity -Metabolic Syndrome

Or Patients -Using Cardiotoxins -Family Hx of CM

Patients with -Previous MI -LV remodeling -LVH -Low EF -Asymptomatic vascular disease

Structural Heart

Disease

Therapy Goals -Treat Hypertension -Smoking Cessation -Treat Lipid Disorders -Regular Exercise -Discourage Alcohol Use -No illicit drug use -Control Metabolic Syndrome

Therapy Goals -Treat Hypertension -Smoking Cessation -Treat Lipid Disorders -Regular Exercise -Discourage Alcohol Use -No illicit drug use -Control Metabolic Syndrome

Therapy Drugs -ACEI/ARB should be only drugs for patients Stage A with no other disease states -HTN should be treated diuretic based HTN meds -Do not use CCB’s or alpha blockers if not required -Restrict Dietary Sodium per DASH diet -Treat hyperlipidemia pert ATP III guidelines

Therapy Drugs -ACEI and Beta Blockers in combination are preferred if tolerated -ARB’s can be used in patients that can not take ACEI because of angioedema or cough

Stage C Structural Heart

disease with prior or current

symptoms of HF

Stage D Refractory HF

requiring specialized

interventions

Patients with -Known structural heart disease -Shortness of breath -Fatigue -Reduced Exercise tolerance

Patients with -Marked symptoms at rest with max therapy Hypertension -Those that can not be discharged from hospital safely without specialized interventions

Develop Symptoms

of HF

Refractory Symptoms

of HF

Therapy Goals -Treat Hypertension -Smoking Cessation -Treat Lipid Disorders -Regular Exercise -Discourage Alcohol Use -No illicit drug use -Control Metabolic Syndrome -Diety Salt restriction 2gm

Therapy Goals -Appropriate measure under A, B, C -Decision Approppriate level of care

Therapy Drugs IN All Patients if tolerated

-ACEI -Diuretics for fluid retention -Beta Blockers

Options -Compassionate end-of-life/hospice

Selected Patient Drugs -Aldosterone antagonist -ARB -Digitalis -Hydaralzine/Nitrates

Devices may be required -Biventricular Pacing -Implantable Defib

Extraordinary Measures -Heart Transplant -Chronic Inotropes -Permanent Mechanical support

-NSAID’s should not be used -Monitor BMP if add Aldosterone Antagonist -Digoxin can be beneficial to reduce hospitalizations no impact on mortality

Initial Studies to Consider for new Heart Failure

BNP/NT-proBNP CBC, BMP, LFT, Iron, Thyroid, Hba1c

EKG CXR

Echocardiogram Referral to Alignment Care Center for disease management

assistance if EF < 50%

Serial Evaluation and Titration of Medications Clinic Visit , Care Center Visit or home visit by Alignment if clinically necessary 1-2 weeks after treatment If volume status requires treatment adjust diuretics f/u 1-2 wks

If euvolemic and stable continue with guideline directed medical therapy f/u 1-2 wks via phone consider repeat BMP Repeat Cycle until no further changes are possible or tolerated

Intensification Phase for first 2-4 months

Lack of Response/Instability

Assess Response to Therapy and Cardiac Remodeling

Repeat Necessary Labs – BMP, BNP/NT-proBNP

Repeat Echocardiogram only if significant deterioration or lack of response to guideline directed medication therapy

Repeat EKG if symptoms warrant

IF EF <35% consider referral to Alignment Care Center Extensivist of Cardiology for eval for CRT or ICD

Remember Acronym to assist in decision making for referral

NEED-HELP

I: IV Inotropes

N: NYHA IIIB/IV or persistently elevated natriuretic peptides

E: End organ dysfunction

E: Ejection Fraction < 35%

D: Defibrillator Shocks

H: Hospitalizations > 1

E: Edema despite increasing diuretics

L: Low BP or High Heart Rate

P: Prognostic medication- progressive intolerance or down-titration of guideline directed medical treatment

Even if patient already has cardiologist consider

Alignment Care Center referral for co-management

Alignment Cardiologist referral for co-management

Alignment Extensivist or Cardiology phone consult to help maximize therapy

Patient can continue with their cardiologist but using Alignment

resources in-house may be more cost-effective for CHF

Journal of the American College of Cardiology December 2017 DOI: 10.1016/j.jacc.2017.11.025

Stage C Heart Failure Reduced EF

Maximize therapy with ACEI/ARB plus

Beta Blocker and Diuretic as tolerated and needed

Patients Stable on ACEI/ARB

NYHA Class II-III

For persistently symptomatic African

Americans NYHA Class III-I

TITRATE DOSE

Patient with persistent volume overload NYHA

class II-IV

Hydralazine and Isosorbide Dinitrate

Diuretics

Patient with resting HR>=7- and maximum tolerated beta blocker dose in sinus rhythm

NYHA class II-III

Patients with GFR >30 and K+ < 5.0

NYHA Class II-IV

Stage C Heart Failure Reduced EF

Maximize therapy with ACEI/ARB plus

Beta Blocker and Diuretic as tolerated and needed

Patients Stable on ACEI/ARB

NYHA Class II-III

For persistently symptomatic African

Americans NYHA Class III-I

TITRATE DOSE

Patient with persistent volume overload NYHA

class II-IV

TITRATE DOSE TITRATE DOSE TITRATE DOSE TITRATE DOSE TITRATE DOSE

ARNI Aldosterone Antagonists

Ivabradine

(Corlanor)

Hydralazine and Isosorbide Dinitrate

NYHA CLASS

NYHA CLASS 1 No Limitation on Physical

Activity

No overt symptoms

NYHA CLASS II Slight Limitation on

Physical Activity Comfortable at Rest

Ordinary Activity Cause symptoms of failure

NYHA CLASS III Marked Limitation on

Physical Activity Comfortable at Rest Less

than Ordinary Activity Cause symptoms of failure

NYHA CLASS IV Inability to carry on any

activity without symptoms

Presence of Symptoms even at rest

Journal of the American College of Cardiology December 2017 DOI: 10.1016/j.jacc.2017.11.025

Select starting dose

HR <50 or symptomatic

HR 50-60

HR> 50

Decrease by 2.5 mg BID

or stop meds

Keep same dose

monitor HR

Increase 2.5 mg

BID until reach max dose 7.5 mg bid monitor

HR

Consider Increasing dose every 2 weeks until max tolerated or target dose achieved

Monitor BP after initiation and during titration

If patient on equivalent of <=160 mg valsartan QD then start 24/26mg BID

If patient on equivalent of >160 mg valsartan QD then start 29/51mg BID

2-4 weeks assess tolerability If possible increase to target

of 97/103 bid

Monitor BP, BMP after initiation and titration

Diuretics

Select Loop Diuretic Dose Consider renal function

Titrate dose to relief of congestion over days to weeks. If increasing

dose of ARB/ACE/ARNI may need to decrease dose of diuretic

Monitor BP BMP after initiation and during titration

If reach high dose of loop diuretic such as 120 mg or > of Lasix

consider Changing to a different loop diuretic Add Thiazide Diuretic to loop diuretic Monitor BP BMP after initiation and

during titration

ACEI/ARB

Select Initial Dose of Aldosterone Antagonists

Consider increasing aldosterone antagonist at least every 2 weeks

until maximum tolerated or targeted dose

Check BMP 2-3 days after starting therapy and then 7 days after titration and then monthly for 3 months - then Q3 months

Before starting make Beta Blockers are adjusted to max tolerated or

target dose

Select Starting dose of Ivabradine

Age < 75 5.0mg BID

Age >=75 2.5 mg BID

Re-assess heart rate in 2-4 wks

Select statring dose as individual or fixed-dose

combination

Ensure 36 hours off ACE, BP OK and GFT >30

before initiating sacubitril/valsartan

Aldosterone Antagonists IVABRADINE (CORLONAR) Hydralazine + Isosorbide dinitrate

ARNI

DRUGS USED TO TREAT HEART FAILURE

BETA BLOCKER

Select initial dose of Beta Blocker

Consider increasing dose of Beta Blocker every 2 weeks until

maximum tolerated or targeted dose

Monitor BP, BMP after initiation and titration

Select initial dose of ACEI or ARB

Consider increasing dose of ACEI/ARB every 2 weeks until

maximum tolerated or targeted dose

Monitor BP, BMP after initiation and titration

Evidenced Based Treatment of Systolic Heart Failure and Chronic Kidney Disease ACEi = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blocker; CRT = cardiac resynchronization therapy;

GFR = glomerular filtration rate; H-ISDN = hydralazine and isosorbide-dinitrate; ICD = implantable cardioverter-defibrillator; MRA = mineralocorticoid receptor antagonist; RAAS = renin angiotensin aldosterone system

Starting dose Target dose Starting dose Target dose

Bisoprolol 1.25 mg once daily 10 mg once daily Eplerenone 25 mg daily 50 mg daily

Carvedilol 3.125 mg twice daily

25 mg twice daily for

weight <85 kg and 50 mg twice daily for

Spironolactone 12.5–25 mg daily 25–50 mg daily

Metoprolol succinate 12.5–25 mg/d 200 mg daily

Sacubitril/ valsartan

24/26 mg–49/51 mg

twice daily

97/103 mg twice daily Hydralazine 25 mg 3× daily 75 mg 3× daily

Isosorbide dinitrate∗ 20 mg 3× daily 40 mg 3× daily

Captopril 6.25 mg 3× daily 50 mg 3x daily

Fixed-dose combination isosorbide

dinitrate/hydralazine

20 mg/37.5 mg (one tab) 3×

daily2 tabs 3× daily

Enalapril 2.5 mg twice daily 10–20 mg twice daily

Lisinopril 2.5–5 mg daily 20–40 mg daily

Titrate to heart rate 50–60 bpm. Maximum

dose

Ramipril 1.25 mg daily 10 mg daily 7.5 mg twice daily

Candesartan 4–8 mg daily 32 mg daily

Losartan 25–50 mg daily 150 mg daily

Valsartan 40 mg twice daily 160 mg twice daily

Ivabradine

ARNI

ACEI

ARB

Starting and Target Doses of Select Guideline-Directed Medical Therapy for HF

Ivabradine 2.5–5 mg twice daily

Digoxin remains indicated for HFrEF, but there are no contemporary data to warrant additional comment

Aldosterone antagonistsBeta Blockers

Vasodilators

Kidney Disease Absent Weak Moderate Strong Hyperkalemia

Stage 1 Diuretics Digoxin/H-ISDN IvabradineACEi/ARB/Beta-

Blocker/MRA/CRT Minimal

Stage 2 Diuretics Digoxin/H-ISDNIvabradine/

ARB

ACEi/ARB/Beta-Blocker/

MRA/CRT/ICD Minimal (+)

Stage 3 Diuretics Digoxin/H-ISDN IvabradineBlocker/

MRA/CRT/ICD Weak

Stage 4

MRA/CRT/ IVABRADINE/

H-ISDN/DiureticsACE/ARB/Digoxin/

ICDBeta

Blocker None Moderate

Stage 5

MRA/CRT/ IVABRADINE/

H-ISDN/DiureticsACE/ARB/

Digoxin/ICDBeta

Blocker None Strong

Source Kevin Damman et al. JACC 2014;63:853-871

HEART FAILURE ZONES

Physician’s Name ___________________________ Weight in office or at discharge ________________

Physician’s Phone Number ____________________ Today’s Date _______________________________

Call physician if weight gain more than _________ pounds one or ____________ in one week

Green Zone

If you have:

Normal Breathing without shortness of breath No Weight Gain More than 2 pounds per day No Chest Pain No Shortness of Breath When Lying Down No Edema or Swelling in your feet, legs, ankles or stomach

ALL CLEAR - You are doing good. Continue what you are doing. Take your Medicine at scheduled times

Eat a low salt diet unless instructed otherwise

Weigh yourself at least daily or more frequently if instructed by your doctor

Yellow Zone

If you have:

Weight Gain of more than 3 pounds in day or 5 pounds in one week or the target your doctor set More difficulty breathing More swelling in legs, feet, ankles or stomach Difficulty with breathing when laying down More tired, dizzy or worse or new coughing

WARNING ZONE- What Should you do?

This zone is your warning Call your doctor’s office

Or you have been assigned Call your Care Manager

Red Zone

If you have:

Struggling to breathe even at rest Difficult breathing with minimal activity Chest Pain or discomfort Feeling Faint or Confusion Rapid or irregular heart rate No Chest Pain

EMERCGENCY -What Should you do?

Get help and go to emergency room Do not DRIVE YOURSELF

Or Call 911

Every Day

Weigh yourself daily before breakfast Write it down and compare to yesterday’s weight Take your medicine as prescribed Check for swelling in your feet, ankle legs and stomach Eat low-salt food and balance activity and rest periods

Which Heart Failure are you in today?

THIS IS YOUR GOAL

This zone is a warning

This zone is an emergency

Review of Evidenced Based Literature for CHF

Diuretics Recommended in order to improve symptoms and exercise capacity in patients with signs and or symptoms of heart failure Should be considered to reduce the risk of HF hospitalization in patients with signs and or symptoms of heart failure

I IIA

B B

Angiotension receptor neprilysin inhibitor (Entresto) Sacubitril/Valsartan is recommended as a replacement for an ACE to further reduce HF Hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with ACE , beta blocker and MRA

I

B

If channel inhibitor

Ivabradine (Corlanor) should be considered to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients with LVEF <35% in sinus rhythm and resting heart rate > 70 bpm despite treatment with an evidenced-based dose or maximum tolerated dose ACE or ARB , and a MRA Ivabradine should be considered to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients with LVEF < 35% in sinus rhythm and a resting heart rate of > 70 bpm who were unable to tolerate or have contra-indications for a beta-blocker . Patients should also receive ACE or ARB and MRA

IIA IIA

B B

ARB An ARB is recommended to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients unable to tolerate an ACE (patients should be on beta-blocker and MRA) An ARB may considered to reduce the risk of HF hospitalization and death in patients who were symptomatic despite treatment with a beta blocker who are unable to tolerate a MRA

IIA IIB

C C

Hydralazine and isosorbide dinitrate Hydralazine and Isosorbide should be considered in African American patients with LVEF < 35% or with a LVEF of < 45% combined with dilated LV in NYHA Class III-IV despite treatment with ACE-A , beta blocker and MRA to reduced risk of HF and hospitalization and death Hydralazine and isosorbide may be considered in symptomatic patients with HFrEF who can not tolerate an ACE or ARB or contra-indicated to reduce Death risk

IIA IIB

B B

Other treatments with less certain benefits Digoxin Digoxin may be considered in symptomatic patients in sinus rhythm despite treatment with ACE or ARB , beta-blocker and MRA to reduce hospitalization

IIB

B

N-3 PUFA (fish oil) An N-3 PUFA may be considered in symptomatic HF patients to reduce risk of cardiovascular hospitalization and death

IIB B

Stage A Treatment Recommendation Level Class Hypertension and lipid disorder should be controlled in accordance with contemporary guidelines to lower risk of HF

1 B

Other conditions that may lead to or contribute to HF such as obesity , diabetes , tobacco use and know cardiotoxic agents should be controlled or avoided

1 C

Stage B Treatment Recommendations In all patients with recent or remote history of MI or ACS and reduced EF, ACE inhibitors should be used to prevent symptomatic HF and reduce mortality . In patients intolerant to ACE inhibitors ARB’s are appropriate unless contraindicated

I

A

In all patients with recent or remote history of MI or ACS and reduced EF evidenced based beta blockers should be used to reduce mortality

I B

In all patient with remote or recent history of MI or ACS statins should be used to prevent symptomatic HF and cardiovascular events

I A

In patient with structural cardiac abnormalities including LV hypertrophy in the absence of history of MI or ACS blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic HF

I

A

ACE inhibitors should be used in all patients with a reduced EF to prevent symptomatic HF even if they I A

do not have history of MI Beta blockers should be used in all patients with a reduced EF to prevent symptomatic HF even without history of MI

I C

To prevent sudden death placement of an ICD is reasonable with asymptomatic ischemic cardiomyopathy who are at least 40 days post MI have and LVEF of 30% or less and are on appropriate medical therapy and have reasonable expectation of survival with a good functional status for more than one year

IIA B

Nonhihdropyridine calcium channel blocker with negative inotropic effects may be harmful in asymptomatic patients with low LVEF and no symptoms of HF after MI

III HARM

C

Recommendations to delay onset of heart failure or prevent death before onset of symptoms Class Level Treatment of hypertension is recommended to prevent or delay the onset of HF and Prolong Life I A Treatment with statins in patients with at high risk of CAD whether or not they have LV dysfunction in order to prevent or delay the onset of HF and prolong life

I A

Counseling and treatment for smoking reduction and reduce alcohol consumption to delay or prevent HF

I C

Treating other risk factors of HF obesity and dysglycemia should be considered to prevent or delay HF IIa C Empagliflozin (Jardiance) should be considered in type II DM in order to delay or prevent HF IIa B ACE-1 is recommended in patients with asymptomatic LV systolic dysfunction without history of myocardial infarction to delay or prevent HF

I B

ACE-I should be considered in patients with stable CAD even if they don’t have LV systolic dysfunction to prevent or delay HF

IIA A

Beta Blocker is recommended in patients with asymptomatic LV systolic dysfunction and history of MI in or to prevent of delay HF

I B

ICD is recommended in patients with asymptomatic LVEF of <30% of ischemic origin who are at least 40 days after acute MI or with asymptomatic dilated cardiomyopathy LVEF <30% receiving OMT therapy to prevent sudden death and prolong life

I B

Pharmacological Treatment of Stage C Heart Failure Reduced EF (HFrEF) Level Class Combining Hydralazine and Isosorbide is recommended to reduce morbidity for African Americans with NYHA Class III-IV receiving optimal other therapy

I A

Combining Hydralazine and Isosorbide can be useful to reduce mortality and morbidity in patients with reduced ejection fraction HF who cannot be given an ACE or ARB

IIa B

Digoxin can useful in HFrEF unless contraindicated to decrease hospitalization IIa B Patients with chronic HF with persistent a-fib and risk factor for stroke (htn,dm, previous stroke, TIA or > 75 age) should receive chronic anticoagulant therapy

I A

Choice of anticoag (warfarin , xarelto, eliquis etc) should be individualized for risk factors, cost etc I C Patients with chronic HF with persistent a-fib and without additional risk factor for stroke (htn,dm, previous stroke, TIA or > 75 age) should receive chronic anticoagulant therapy

IIa B

Anticoagulation is not recommended in patient with HFrEf without AF , prior embolic event or cardioembolic source

III B

Statins are not beneficial as adjunct therapy when prescribed solely for diagnosis of HF in absence of other indications for use

III A

Omega 3 are reasonable to use with NYHA class II-IV and HFrER or HRpEF to reduce hospitalization and mortality

IIA B

Nutritional supplements as treatment for HF are not recommended with current or prior HFrEf III B Hormonal therapies other than to correct deficiencies are not recommended for patients with HFrEF III C Most antiarrhymic drugs , calcium channel blockers (except amlodipine), NSAIS and TZD are potentially harmful in patients with HFrEF

III B

Calcium channel blockers are not recommended as routine treatment for patients with HFrEF III A

Pharmacologic Treatment of Stage C Heart Failure with Preserved Ejection Fraction HFpEF Level Class Systolic and Diastolyic BP should be controlled with clinical practice guidelines to prevent morbidity I B Diuretics should be used for relief of symptoms of volume overload in HFpEF I C Coronary Revascularization is reasonable in patients in which symptoms are judged to have adverse impact on HFpEF

IIa C

Management of Afib to clinical published guidelines in HFpEF is reasonable to improve symptomatic HF IIA C The Use of Beta-Blocking Agent ACE, ARB with HTN is reasonable to control BP in patients with HFpEF IIA C The Use of ARB may reduce hospitalizations in patients with HFpEF IIB B Routine use of nutritional supplements in not recommended for patients withHFpEF III C

Patient Cohorts

Description Evidence-Based Recommendations

Risks Uncertainties

African Americans

Self-identified (GDMT) Guideline-Directed Medical Therapy

Increase incidence of angioedema compared to Caucasian patients with use of ACEI, ARB, and ARNI: Seemingly higher risk of hypotension, dizziness with use of Hydralazine and Isosorbide Dinatrates

Treatment with certain drugs have less predictable outcomes including ARNI and/or ivabradine in those treated with HYD/ISDN

Older adults

≥75 years Use GDMT but with much more cautious approach as doses may need to be lowered . Older patients tend to have higher incidence of complications with use of device therapy

Hypotension with increased incidence of falls, quicker deterioration of kidney function, polypharmacy, fixed incomes with consider drug costs , comorbidity

Because may be forced to use lower dose of GDMT outcomes may not be as effective as in other groups

Frail wt loss, weak, slow walking, exhausted, limited activity

Use dose of GDMT the patient can tolerate

Could be increase in adverse drug reactions. Response to GDMT less predictable

Difficult to assess efficacy of treatment on overall health in frail with HF

ACEI = angiotensin converting enzyme inhibitors; ARB = angiotensin receptor blockers; ARNI = angiotensin receptor-neprilysin inhibitor; GDMT = guideline-directed medical therapy; HF = heart failure; HYD/ISDN = hydralazine/isosorbide dinitrate.